Understanding the Antimalarials Market in Uganda Rosette Mutambi, - - PowerPoint PPT Presentation

Understanding the Antimalarials Market in Uganda

Rosette Mutambi, HEPS Uganda Martin Auton, Health Action International, The Netherlands ASTMH, December 7 to 11 2008 New Orleans New Orleans

Key findings

• 1. Recommended treatment is provided free in the public/mission facilities,

but is not always available

• 2. ACTs are many times more expensive than the older ineffective medicines
• 3. Complete courses of all antimalarial medicines are unaffordable to a

significant proportion of the population

• 4. A family has to choose between basic needs like food and education, or

purchasing medicines for the treatment of malaria

• 5. Components of the final patient price are very different for different types
• f medicines in different types of outlet

(e.g. manufacturers selling price, supply chain mark-ups)

• 6. Study provides an evidence base to guide initiatives to replace older

ineffective medicines with ACTs

• Availability of product by
• utlet type
• Range of prices
• Affordability
• Affordability
• Supply chain structure &

mark-ups

• Management & rational use

Methodology

• Evolved from the WHO/HAI Medicine Prices

Methodology [www.haiweb.org/medicineprices]

• Census approach across 9 districts of Uganda
• everywhere selling medicines:
• 750 outlets: public, mission &

for-profit; formal & informal

• all antimalarial medicines found:
• 174 different entities, formulations, strengths

and manufacturer permutations

• Mapped outlet spatial locations using GPS
• Supply chain and mark-ups investigated in Kampala (capital city & main

commercial centre) plus 2 study districts

• Medicines for Malaria Venture in collaboration with Ministry of Health

and Civil Society (HEPS)

• June – September 2007

Only 16% of the

• utlets located in some

Districts provided public sector care Access to free public sector treatment can be limited public sector care

(84% being for-profit)

Only 50% of public health facilities in some districts had any of the Access to free public sector treatment can be limited first-line recommended treatment

(ACT: artemether-lumefantrine)

As many as 45%

• f the outlets in some

districts were not Access to licensed outlets can be relatively low supposed to sell medicines

(i.e. not licensed, informal)

ACTs: up to 60 times more expensive compared to older (ineffective) antimalarials Effective medicines are more expensive

11 days

average household income to purchase a Effective medicines are unaffordable single course of ACT for a 5 year old child

A family would need to forego 62 days of basic food in order to Effective medicines are unaffordable afford annual needs of ACTs from the private sector

The poorest 40% population cannot even afford the price of the The poor cannot afford the cheapest medicines cheapest antimalarial found on the market (chloroquine)

Only 50% purchased a full course of even the lower priced (ineffective) Unaffordability contributes to irrational use antimalarials

As few as 4% of private sector outlets in some districts stocked ACTs are unaffordable so not widely stocked by the private sector ACTs

As much as 90% of the final patient price in Uganda can be the retail mark-up

Price structures vary widely between products & sectors

90% SP Clinic (locally produced) 27% 46% 60% 63% 68% ACT Mission (imported) SP Pharmacy (imported) ACT Clinic (imported) SP Clinic (imported) CQ Drug shop (locally produced)

Conclusions

• The public and private sectors are both significant providers of

antimalarial medicines

• ACTs are not always available in the public sector and are

unaffordable in the private sector

• Different interventions are needed for the public and private
• Different interventions are needed for the public and private

sectors in order to increase access for all of the population

• There is a private sector supply chain to the village level

(the older ineffective medicines get there)

• This study provides an evidence base for policy makers in

Uganda and internationally to guide initiatives to replace older, ineffective medicines with ACTs

Widen distribution through OTC status

Using the evidence: a pilot study to assess the impact of making subsidized ACTs available via the private sector

Political buy-in Supply chain incentives to sell lower priced product Generating demand for ACTs Training providers Tracking progress & impact

Using the evidence: Civil Society

• Expanding the understanding of impact of medicine prices

and availability on health

• Developing simple messages on medicine prices and

availability for different audiences

• Engaging policy makers at different levels to be aware of

Engaging policy makers at different levels to be aware of impact of price and availability on health

• Public and media debates
• Justification for allocating for improving medicine

management and money for medicines (Ministry of Finance)

• Using the evidence to monitor whether access expands to

the poor

“350 Ugandan children die every day due to malaria in my

• country. This report provides clear evidence on how we can make

life-saving ACTs available to this vulnerable population.”

• Hon. Dr. Stephen Mallinga, Minister of Health, Uganda

Affordability assumptions

• Family size 5.2: 2 x adults1
• Typical age structure: 1 x 15yrs; 1 x 7yrs; 1 x 2yrs2
• Annual malaria episodes: 2yr old: 4x; 7yr old: 3x; 15yr
• ld & adults: 2x 3
• Average income = cash plus inkind1
• Food needs: 2,100 K/cal per day4
• Full treatment courses
• Median prices of medicines and food items

1. 2005/6 Uganda National Household Survey 2. 2002 Uganda National Census 3. Ministry of Health 4. WFP/UNICEF